General Surgery

Varicose veins in the legs develop due to Venous Incompetence of certain valves, the commonest being in the groin, and others being behind the knee, in the thigh and in the calf.

Standing leads to higher pressure the further away from the heart that the column of blood is, where the forces of gravity cause high  hydrostatic pressure, leading to swelling into the subcutaneous tissues, secondary to the high pressure in the veins with blood flowing backwards instead of back to the heart, because of the non-functioning valves.  This leads to swelling in the lower leg around the ankles particularly, and subsequently itchiness and discomfort and aching.  Quite apart from the physiological affects just described, the cosmetic problems of swollen, lumpy varicose veins are significant  for many people.  Occasionally bleeding can occur from subcutaneous prominent varicosities. 

The treatment of symptomatic varicose veins is focussed around reducing the hydrostatic pressure in the veins, by disconnecting the incompetent veins at the level where valves are no longer functioning properly.  Usually this involves an incision in the groin which is a subcutaneous operation and not particularly painful to recover from.

The reasons for recommending treatment are to resolve the symptoms described, to prevent further deterioration in the tissues of the lower leg which can even lead to ulceration and discolouration, and also to improve the cosmetic appearance.  Small “spider veins” in the skin are also secondary to venous incompetence, and may improve somewhat after surgery to treat the main sources of incompetence, but may need some treatment in their own right from a cosmetic point of view later on. 

Surgery has remained the mainstay of treatment of varicose veins, and can lead to great improvement in symptoms and cosmetic appearance.  Patients are always made aware, however, that the very nature of venous incompetence development over time means that there can be further such incompetence and then new varicosities in future years, but there may well not be. 

Another treatment available now is Endovascular Laser Ablation of varicosities, which can be done under local anaesthetic under ultrasound control, in specialists rooms.  This therefore can be quite expensive as it is not covered under private health insurance.  This treatment, however, allows access to more complex variations in venous incompetence including pelvic vein incompetence, and perforator incompetence, and allows better access to these varieties of incompetence, than does surgery.

Recovery after surgery involves wearing bandages for the first few days, elevating the leg, and then wearing a supportive compression stocking for about a week post-op, or longer if it conveys ongoing comfort for a patient.  Patients who undertake active work involving standing or sitting for lengths of time will need between two and three weeks away from work usually. 

The surgery for varicose veins is conducted under general anaesthetic, and is not greatly painful in the immediate recovery phase.  Occasionally there can be thrombosis in some of the veins tied off (which is not dangerous in any way) which can cause prolonged discomfort until this resolves spontaneously. 

The common indications for surgery for thyroid disease are goitres (generalised benign enlargement of the thyroid gland) and solitary thyroid nodules, which require excision to exclude cancer.  There are some other thyroid conditions which less commonly act as indications for surgery. 

Enlarged thyroid glands present with symptoms of pressure in the neck, or just a visible lump.  Occasionally pain due to Thyroiditis can be associated.

An ultrasound examination together with clinical examination represents the principle ways of assessing the thyroid gland, together with thyroid function blood tests.

The management of a solitary thyroid nodule would be discussed in detail with your surgeon, particularly focussing on ways of excluding cancer and treating cancer if needed.  It should be understood that the common forms of thyroid cancer, both papillary and follicular types, are totally curable and at least 90% of cases, through thyroid surgery alone. 

If thyroid surgery is recommended then this will be discussed in detail.  It should be understood, however, that the thyroid gland is a subcutaneous gland, and surgery, done under general anaesthetic, does not result in a large amount of pain post-operatively.  Patients stay in hospital usually one or two nights.  Sometimes a longer stay is required if calcium metabolism needs adjusting due to involvement of parathyroid glands.  If the whole thyroid gland needs removal then patients will need to have replacement thyroid hormone tablets daily for the rest of their life.  Complications can involve hypo-parathyroid function with the need for calcium replacement, or recurrent laryngeal nerve palsy, both of which can occur in approximately 3% of patients.

Thyroid surgery, while intricate, is not demanding of a long stay in hospital, and, for the indications outlined, usually gives excellent results for patients.  The surgical scar in the neck is usually very cosmetically acceptable.  

Vasectomy is a surgical procedure with a social indication rather than a clinical abnormality as an indication.  It is, however, probably the most guaranteed form of permanent contraception available.  Some important factors to be aware of include the following:

• The procedure involves approximately  a 20 to 30 minute operation, best done under a general anaesthetic or intravenous sedation.
• The operation should be regarded as irreversible.
• Sterility is not achieved until lack of sperm in the semen is proven on testing post-operatively.  This will be clearly described to you by your surgeon.
• Vasectomy simply interrupts the flow of sperm, but  in no way causes any change in sexual function.
• Sterility will be confirmed several weeks post-operatively after a semen analysis is done, under your surgeon’s guidance.
• In the post-operative weeks before semen analysis, sexual activity should be continued, with contraceptive precautions.
• Vasectomy will lead to some bruising around the genital region, which resolves spontaneously.  Most people require approximately three days away from work.  

The commonest forms of herniae are protrusions through the abdominal wall into the subcutaneous tissues, of abdominal contents (fatty tissue and sometimes bowel).  Herniae can present just as a lump, but often have some discomfort or even severe pain associated.  On very rare occasions hernias can contain strangulated bowel and require urgent treatment.  Most herniae, however, are treated very electively and do not present risks of strangulation. 

• The commonest herniae are inguinal (groin) herniae in men, but these can occur in women too.
• Other common herniae include umbilical and epigastric herniae, higher in the abdomen. 
• Incisional herniae are ones which occur in previous surgical wounds.
• The fundamentals of successful treatment are based around reducing the hernia back to the abdomen, and repairing the hernial opening without tension, usually involving suturing polypropylene mesh in place, for anything but very small hernias. 
• Hernia operations are usually done under general anaesthetic but sometimes can be done under local anaesthetic.
• The recovery period necessitates approximately six weeks away from strenuous activity to allow tissue healing into the mesh to make the full strength of the repair complete. 
• With a good operation and appropriate care for six weeks post-op, there is a minimal chance of recurrence of a hernia (approximately 2%).
• While laparoscopic (keyhole) hernia operations can be done, the operation with lowest recurrence rate and least risk of major complications remains the open mesh hernia repair described.  

A very debilitating condition is caused by pressure on the median nerve at the wrist in the narrow “carpal tunnel” through its tendons past the hand.  When longstanding, this can cause permanent nerve damage and weakness as well as sensory (feeling) loss.

• Diagnosis is made clinically but confirmed with nerve conduction studies.
• Surgery is made through a very small wrist incision, with full decompression of the median nerve performed. 
• The procedure is a short one and is conducted as a day case. 
• The patient is able to use the hand for almost all functions from immediately post-operatively onwards and post-operative pain is not great.
• Relief after surgery is almost immediate, from the pre-operative symptoms which include numbness and tingling into the hand and pain in the hand, wrist and forearm.
• Both hands can be operated on in the same procedure, but it is usually advised to stay one night in  hospital post-op in that instance.

This fibrous tissue contracture, arises from the deep layers of the skin, and presents as bands forming in the palm of the hand and into some fingers or thumb.  It is common in people of Anglo-Saxon descent. 

• Surgery is indicated when the contracture causes a significant  flexion deformity of a finger, or symptoms of pain are problematical.
• Surgery is focussed around resecting the affected area of skin in the hand, together with the underlying fibrous scar band, and releasing the contractures. 
• Closure is either with local skin flaps or full thickness skin graft.
• Full recovery can take quite some weeks, but results in the opening up of the hand and a more functional result for the patient.
• Sometimes digital nerves are intricately involved with the fibrous scar tissue and some numbness can exist in parts after surgery.

The commonest pilonidal sinus problems are those involving the natal cleft (between the buttocks).  The condition develops from hairs being buried under the skin and becoming infected.

• The treatment which leads to least risk of recurrence involves resection of the pilonidal sinus, and then healing by the wound being left open with varying types of dressings applied.  Negative pressure suction dressings often present the best and quickest result.
• Sometimes primary surgical suturing and closure is possible.  

These present at the commonest “lumps” that people notice around their body, and are benign (non-malignant) lesions which can be excised readily, usually under local anaesthetic unless the size or position dictates a need for some associated intravenous sedation or general anaesthetic.  The surgery involves excision of the lipoma or cyst and closure simply, sometimes with dissolvable buried sutures or sometimes with firm sutures to hold the skin against body movement during healing.  These surgical procedures are normally day procedures .

A ganglion is an encysted collection of synovial fluid associated either with a joint, usually the wrist, or tendons, wherein the lubricating fluid or synovial fluid contained in the joint or tendon has leaked into surrounding tissues and become encapsulated in a thin cyst like bag.  These can present with some aching discomfort and a visible lump.

Surgical excision of ganglia is conducted usually as a simple day case procedure with careful excision around the thin-walled cyst to remove it from its attachment to the underlying joint or tendon and seal the connection so that further fluid leakage does not occur.  Usually the area is immobilised for 7 to 10 days post-operatively to reduce the risk of recurrent development.  The surgery is not particularly painful to recover from in most instances.

Commonly small skin cancers including basal cell cancers and squamous cell cancers present as itchy and persisting, sometimes bleeding, small areas anywhere on the body.  These can be cured in almost all instances by early excision and closure, often just under local anaesthetic.  When on difficult areas with minimal loose skin, small skin grafts have to be applied which are often best as full thickness grafts taken from an adjacent area of skin, and this can often all be done with local anaesthetic.  Sometimes closure of the area involves the use of small local skin flaps moved into the area with closure behind.

All tissue excised in the above descriptions is submitted for histopathological examination.